Diabetes mellitus is accompanied by serious complications and reduced life expectancy. It affects approximately 25% of patients receiving care in the Veterans Health Administration (VA).In approximately 80% of adult patients with diabetes death results from cardiovascular disease, most often coronary artery disease or cerebrovascular disease. These are conditions that must be satisfactorily managed in order to improve survival. Over recent decades a number of ambulatory care interventions have been shown to result in a substantial reduction in mortality due to cardiovascular disease. Thus, it is reasonable to expect that high quality outpatient care can achieve a meaningful improvement in the overall survival of patients with diabetes. It is known, however, that quality of care for patients with diabetes varies across VA facilities and it is likely that there is variation in patient mortality well. In preliminary work, we have found VISN-level effects on survival that support this probability. This variation in VISN-level mortality raises concern that there will be still larger variation across facilities, because facilities are more heterogeneous than VISNs in the quality of care that they provide. We have developed and validated a risk adjustment method for mortality rates of ambulatory care patients over the course of two previously funded VA HSR&D IIR proposals. We now propose to optimize it for patients with diabetes in order to examine the relationship between the quality of ambulatory care and the mortality of patients with diabetes across VA facilities. Our overall objective is to obtain information that will make it possible to reduce the mortality of VA patients with diabetes. The specific objectives are: 1) To modify our risk-adjustment method so as to optimize its performance in predicting the mortality of ambulatory care patients with diabetes. 2) To determine the degree to which facility mortality rates correlate with life-prolonging goals of treatment. 3) To determine how well facility mortality rates correlate with other recommended processes of care. This study will provide information about the mortality rates of ambulatory care patients with diabetes across all Veterans Health Administration (VA) facilities. It will determine the degree to which variation in mortality is due to variation in quality of care. Thus, it will provide information about which facilities need to improve, in what way, and the reduction in mortality that will result.